Normal ejaculation involves the processes of emission and expulsion of semen, which are controlled by the nervous system.

So what triggers ejaculation? The voluntary cause for ejaculation include tactile stimulation of the glans penis and various supraspinal processing of the thermal stimuli.

When a man is ready to ejaculate, signals are sent to the spinal reflex under supraspinal control. This causes seminal fluid to be ejected from the urethral meatus (penis), which is commonly accompanies sexual climax or orgasm.

During the emission phase, the secretion of seminal fluid from the prostate and the seminal vesicles, contraction of the smooth muscles of the seminal tract from the epididymis to the prostate to transport the ejaculate, closure of the bladder neck and the internal urethral sphincter, and the ejection of sperms into the posterior urethra.

Expulsion happens when the semen is forcefully forwarded through the urethral meatus by rhythmic contractions of the pelvic floor muscles and the bulbospongiosus muscles out of the penis.

When a man is sexually aroused, the brain sends signals to the penis area through nerves in the spinal cord to contract the pelvic muscles. The final outcome of his sexual arousal is the release of a semen from the tip of his penis, thus the term called “ejaculation”.

Ejaculation is usually accompanied by orgasm. The fluid secretions that he released out from his penis is the mixture of sperm cell and semen.

Premature Ejaculation also known as the “inadequate ejaculatory control“, is the inability to exert voluntary control over the ejaculatory reflex. It occurs when a man reaches a certain level of sexual arousal or excitement. He then ejaculates either before or shortly after sexual penetration than he or his partner would like.

Clinical studies have used assessment measurement such as intravaginal ejaculatory latency time (IELT) to define premature ejaculation. IELT refers to a measurement at-each-coitus using a stopwatch handled by a partner. According to a multinational population survey of IELT by Marcel Waldinger et al. revealed that 90% of 110 had an IELT or an early ejaculation of less than 60 seconds.

There is no universally accepted definition and classification for premature ejaculation. However, most reputable organizations have come up their own definitions, for example:

(1.)Masters and Johnson:

Premature ejaculation as the man’s inability to control ejaculation long enough to satisfy his partner. PE happens with minimal sexual stimulation and before a man wants it to happen.

(2.) American Urological Association:

Ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either or both partners

(3.) World Health Organization (WHO):

Inability to delay ejaculation sufficiently to enjoy lovemaking, manifest as either of the following: a) occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required: before or within 15 seconds of the beginning of intercourse); and b) ejaculation occurs in the absence of sufficient erection to make intercourse possible.

(4.) International Consultant on Sexual Dysfunction:

Ejaculation with minimal stimulation and earlier than desired, before or soon after penetration, which causes bother or distress, and over which the sufferer has little or no voluntary control

(5.) International Society for Sexual Medicine (ISSM):

A male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.

The primary symptom of premature ejaculation is the inability to control ejaculations. This commonly results in secondary psychological symptoms, including lack of self esteem, sexual anxiety performance and relationship issues.

Currently, there are four different types of PE, namely:

(1.) Lifelong (also referred as ‘Primary PE’ )

Lifelong PE is a chronic ejaculatory dysfunction. The problem has always existed since the first sexual experience and continues throughout life. Some men already get an ejaculation during foreplay prior to penetration (ejaculation ante portas), or shortly as the tip of their penis touches the vagina (ejaculation intra portas).

Symptoms of Lifelong PE include:

ejaculation happens way too early at almost everyone intercourse with nearly every partner

ejaculation occurs too fast before vaginal penetration within 30-60 seconds or between 1-2 minutes and it remains rapid during life

(2.) Acquired (also referred as ‘Secondary PE’)

Acquired premature ejaculation is usually indicates that someone had a period of normal functioning before the premature ejaculation began, but started suffering from PE at some point later in his life.

It is characterized by the following symptoms:

early ejaculation occurs at some point in a man’s life

a man has usually had normal ejaculation experiences before the start of complaints

the dysfunction may be due to urological dysfunction like erectile dysfunction or prostates, thyroid dysfunction, and psychological issues or relationship problems

(3.) Natural Variable Premature Ejaculation

Men may experience early ejaculations in situational or coincidental conditions.

The syndrome is characterized by the following symptoms:

early ejaculations are inconsistent and occur irregularly

the ability to delay ejaculations at the moment of imminent ejaculation may be diminished

experiences of diminished ability to delay ejaculation go along with either a short or normal ejaculation of less or more than 1.5 min

(4.) Premature-like Ejaculatory Dysfunction

Men with premature-like ejaculatory dysfunction have always had it and never been able to gain control once they are sexually aroused.

Although the exact causes of PE are not fully understood, new studies concluded that premature ejaculation can be a complex interaction of biological, psychological or a combination of both.

In most cases, anxiety and early sexual experience are perhaps the most contributing factor of premature ejaculation. However, ejaculation is primarily influenced by the central nervous system control, it doesn’t mean that some men may also inherent physical cause for being more easily aroused or sensitivity in the skin of the penis than other men are.

Biological causes of premature ejaculation include:

Abnormal levels of brain chemicals called neurotransmitters that have been found in men with premature ejaculation

Abnormal reflex activity of the ejaculatory system due to an autonomous reflex

Highly responsive nervous system. If your sympathetic nervous system is highly responsive, it can lead to an early triggering of an orgasm and eventually premature ejaculation

Diagnostic evaluation of premature ejaculation is based on a person’s medical and sexual history. In order to determine whether PE is situational or consistent, history gathering should classify PE as lifelong, acquired, natural variable premature ejaculation, or premature-like ejaculatory dysfunction. Special attention should be given to the duration time of ejaculation or the IELT, degree of sexual stimulus, impact on sexual activity, and drug use or abuse.

It is also important to distinguish between PE from ED because many patients with ED develop secondary PE caused by performance anxiety associated with difficulty in achieving and maintaining a solid erection.

The treatment of premature ejaculation should alleviate the symptoms of the condition and increased satisfaction by controlling rapid ejaculation. Therapy especially the behavioural approach requires a lot of patience, understanding, dedication, and commitment by both partners.

Currently, there are various treatment options for premature ejaculation. The conventional way of treating PE includes behavioural, psychological, and pharmacological interventions.

(a.) Behavioural and Cognitive Therapy

Behavioural techniques for premature ejaculation can help delay ejaculation as much as by 60-90% if done properly and with constant practice.

CBT involves the “squeeze techniques” and the “start-stop method”, which is fully described below.
(1.) Squeeze Technique

Image 1: porterbrookclinic.org.uk

Image 2: porterbrookclinic.org.uk

The squeeze method was popularized by Masters and Johnson in 1970.

In the squeeze technique, the glans or the head of the penis is squeezed firmly between the thumb and the forefingers, with your thumb on the frenulum, and the two fingers on the opposite side of the penis where the glans meets the shaft of the penis (see image 1 & 2 ).

Squeeze hard for several seconds when you feel you are about to ejaculate. Please keep in mind that this technique may take a lot of practice to be successful in controlling premature ejaculation.

After the squeeze is released, you may have to stop any sexual stimulation for at least 30-45 seconds before resuming sexual activities. The idea of a squeeze technique is to interrupt your ejaculation through squeezing and recognize the “point of no return” so that you may be able to delay future ejaculations. You may repeat this technique for up to 4-6 times until you decide not to delay ejaculation anymore.

(2.) Stop-start technique
Another trick to stop premature ejaculation is the “stop-start technique”, first introduced by Dr. J. Semans in 1956. It involves by stimulating the penis and stopping just when you feel that you are going to come. Relax and stop the stimulation for about 30-60 seconds and then restart again once the feeling of ejaculating is gone. You may repeat this technique for up to 4-6 times or until you wish to ejaculate.

(3.) Control During Penetration
Once you have mastered either stop-start or the squeeze technique, you may incorporate this techniques during intercourse. Just keep in mind, when you feel that you are going to ejaculate during penetration, just stop and apply either stop-start or the squeeze technique.

(4.) Masturbation Before Sexual Intercourse
This technique is mostly used by many younger men. Masturbation before sex can desensitized the penis resulting in greater ejaculatory delay after the recovery period. However, bad masturbation practice can further impede the development of rapid ejaculation control mechanism.

(b.) Other Techniques to Help Eliminate Rapid Ejaculation

The “squeeze” and “start-stop” techniques are proven to be effective when combined with other techniques below.

(1.) Kegel Exercise

Kegel exercise also known as the “pelvic floor exercise” was developed by Dr. Arnold H. Kegel as a a nonsurgical way to prevent incontinence for both men and women.

Kegel exercises has been shown to help men’s erections to last longer as well as help with ejaculation control. The action of repetitive contraction of the pelvic floor muscles create strong pubococcygeus muscle (PC muscle).

The easiest way to locate your pelvic floor muscle is while urinating, try to stop or slow your urine in midstream. The muscle that corresponds the stoppage of your urine is your pelvic floor muscles.

To do the Kegel exercises, you will quickly clench and release the PC muscle repeatedly for 10 seconds. Repeat this routine until you’ve done the 100-200 clenches. Don’t forget to take a short break in every set. By strengthening your pelvic region, you’ll be able to hold your ejaculation for up to 1 hour or for as long as you want.

(2.) Triangular Breathing Technique

This technique of holding ejaculation works by taking a triangular breathing when you are about to come. This mehtod brings about a deep level of calmness and increases level serotonin production. Deep breathing helps control the arousal and relieves performance anxiety that leads to an early ejaculation. To do the triangle breathing:

1. Inhale for 3 seconds

2. Pause and hold for 3 seconds

3. Exhale for 3 seconds

4. Repeat the process

(3.)Wearing thick condoms

Thick condoms can help decrease penile sensitivity especially the glans, thereby decreasing the level of arousal and early ejaculation incident.

(4.) Mental distraction

Another method to delay ejaculation is through mental distraction, you think something about nonsexual to distract your arousal. Some guys are imagining counting from 1 to 1000 or counting down from 1000 to 1, which may also help to delay orgasm and premature ejaculation.

(c.)Pharmacologic therapy may include the following:

Topical desensitizing creams or sprays (eg, lidocaine and prilocaine) are used before sex to treat premature ejaculation. This temporary solution for premature ejaculation works to reduce the sensitivity of the penis in order to prolong ejaculation. Potential side effects include temporary loss of sensitivity and decrease pleasure.

Selective serotonin reuptake inhibitor (SSRI) therapy (eg, sertraline, paroxetine, fluoxetine, citalopram, or dapoxetine). These drugs are often prescribed to help delay ejaculation. However, these medications can cause erectile dysfunction as well as decrease libido.